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University of Missouri (MU) Health Care utilized the AHRQ toolkit Preventing Pressure Ulcers in Hospitals to decrease PSI-03 (reportable pressure injuries) by 92% and save an estimated $350,000 in avoidable costs. Implementation focused on MU Health Care’s 390-bed University Hospital, the only Level I trauma center in central Missouri.

In alignment with the AHRQ toolkit, MU Health Care began this journey by assessing the need for hospital-acquired pressure injury (HAPI) reduction and the system’s readiness to create focused efforts around this goal. All-cause HAPI rates and PSI-03 were sustained at a higher- than-expected occurrence, which has a negative impact on patient care, various financial aspects, and national rankings across multiple programs. MU Health Care was performing at the 87th percentile ranking among Vizient peers, while the target was top quartile performance.

In February 2019, a formal project was initiated to reduce HAPIs and a plan was devised for managing the change. A multidisciplinary team was formed, supported by an executive sponsor, the CNO, a physician lead, and a nursing lead. Other team members included representatives from quality; data analytics; information technology; and content experts, such as wound care nurses.

The HAPI reduction project was launched through MU Health Care’s Performance Improvement (PI) Priorities Program. This program was established to identify and resource projects for quality improvement that align with strategic priorities. The project team met weekly and provided progress updates to PI Priorities Program leadership every other week. This structure provided resources and an escalation pathway for barriers. The project spanned two phases: the first focused on general HAPI prevention (February 2019 - July 2020) and the second focused on reducing risk related to equipment (February 2021 - September 2021).

During each phase of the project, the team began with a current state assessment and deep dive into the root causes of identified pressure injuries, along with an assessment of best practices for prevention. Root causes identified included proning, equipment such as rectal tubes and tracheostomy plates, and not recognizing deep tissue injuries and pressure injures present at the time of admission. Interventions for this project were varied and distributed across the continuum of intervention effectiveness utilizing people, process, and technology.

One of the most impactful initiatives was a debrief process, referred to as a “SWARM,” that took place after a new pressure injury was documented by a staff member. The SWARM involved a multidisciplinary team, including skin experts, investigating the root causes of injury. The process embedded expertise for coaching and teaching and provided visible leadership support for the project with director of nursing and manager attendance. Workgroups addressed issues identified, such as development of proning guidelines and safety checklists, criteria for rectal tube removal, and trials to evaluate products for more skin-friendly options.

The electronic medical record (EMR) was utilized in numerous ways to inform team members and prompt action. For example, the skin care team is notified when new documentation occurs for pressure injuries so that the SWARM process may begin. Additionally, the skin care team is notified through the EMR when new tracheostomies are placed. Physicians and nursing staff receive alerts when tracheostomy sutures are in place longer than recommended so they may be removed and relieve pressure from the faceplate. Tasks remind staff to complete the head-to-toe skin assessment by two nurses known as 4E4H (4 eyes in 4 hours) and to utilize the wound scout, a thermal imaging device that can identify possible deep tissue injury.

As evidenced by the examples above, the interventions developed out the of HAPI reduction project were multidimensional. Some standardized interventions, such as 4E4H and Braden scoring, were applied consistently across the inpatient population. Other interventions were applied with consideration to the unique needs of populations or patients determined to be more at risk. For instance, patients with a Braden ≤ 15 were placed on an alternating pressure mattress, and patients in the intensive care unit or with non-blanchable redness were evaluated using a wound scout. Utilizing a multifaceted approach allowed for individualized, patient-centered care.

The HAPI reduction project saw initial positive results in process metrics, such as a 95% adherence to 4E4H across the system and 90% wound scout utilization in the medical intensive care unit. With the project’s goals beginning to be realized, the team applied the AHRQ toolkit’s recommendations for monitoring and sustainment. Adherence and progress toward goals were monitored in a variety of ways. During the project phases, the team reported process and outcome metrics every other week to PI Priority Program leaders. During and after the project, this information was available to unit leaders through a nursing dashboard. Information captured by the SWARM process was tracked on a dashboard that could be filtered by unit.

Real-time reports are used to capture process metrics, such as adherence to 4E4H, turn rates, and appropriate bed utilization, and are available to unit leaders via an electronic nursing dashboard. The internally developed dashboard combined the care bundle and allowed supervisors to follow up with staff on missing elements in the moment.

MU Health Care is proud to share that substantial and sustained improvements were noted as a result of this project and the implementation of the AHRQ toolkit. This improvement is seen in both all-stage HAPI and PSI-03 metrics. Over the course of 2 years, MU Health care exceeded the goal of top quartile performance by rising to the top decile. The baseline period saw 26 PSI-03 events, while the post-implementation period saw only two, a 92% reduction. Before the project, University Hospital sometimes had as many as 20-25 all-stage HAPIs per month.

Following the project, the average number of all-stage HAPIs has decreased to four and has been sustained from project end to the time of this report in September 2023.